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You need to enter a name
You need to enter a position
You need to enter an address
You need to enter a UK postcode
You need to enter a phone number

You need to enter a name
You need to enter an address
You need to enter a UK postcode
You need to enter a phone number
You need to enter a valid date of birth
I would like BALP to contact the individual directly
You need to choose if you would like BALP to contact the individual directly

Are you currently engaged in mental heath services?
You need to tell us if you're currently engaged in mental health services
Have you previously been engaged in mental health services?
You need to tell us if you've previously been engaged in mental health services
Are you unable to access mainstream activity due to your mental health?
You need to tell us if you're unable to access mainstream activity due to your mental health
Which of the following mental health services are you currently engaged in?
You must tell us which mental health service you're currently engaged in.
You need to tell us which activity or activities from the timetable you would like to participate in

You need to enter a name
You need to tell us your relationship to the person
You need to enter a phone number

Has your doctor ever said you have a heart condition?
You need to tell us if your doctor has ever said you have a heart condition
Have you ever been told to only participate in exercise that is prescribed for you?
You need to tell us if you have ever been told to only participate in exercise that is prescribed for you
In the past month, have you had chest pain when you were not doing physical activity?
You need to tell us if, in the past month, you have had chest pain when you were not doing physical activity
Do you feel pain in your chest when you do physical activity?
You need to tell us if you feel pain in your chest when you do physical activity
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
You need to tell us if your doctor is currently prescribing drugs for your blood pressure or heart condition
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
You need to tell us if you have you have a bone or joint problem that could be made worse by a change in your physical activity
Do you lose your balance because of dizziness or do you ever lose consciousness?
You need to tell us if you lose your balance because of dizziness or ever lose consciousness
Do you have Epilepsy?
You need to tell us if you have Epilepsy
Do you have Diabetes?
You need to tell us if you have Diabetes
Do you have Asthma?
You need to tell us if you have Asthma
Are you pregnant?
You need to tell us if you are pregnant
Do you smoke?
You need to tell us if you smoke
Have you had any changes in medication in the last two weeks?
You need to tell us if you have had any changes in medication in the last two weeks
Do you know of any reason why you should not participate in physical activity?
You need to tell us if you know of any reason why you should not participate in physical activity
Do you have any health conditions or are you taking any medication that we have not asked about?
You need to tell us if you have any health conditions or are taking any medication that we have not asked about

I give my consent for this form to be used for evaluation purposes and to help secure future funding (personal identification will not be used)
You need to tell us if you give your consent
You need to tell us how you heard about BALP
Please tick here if you're happy to be updated:To help with the BALP experience we aim to be as efficient and as environmentally friendly as possible. Instead of sending you information by post, we would like you to download information from our website. Where possible we'll contact you by email to keep you up to date with the BALP scheme.

Terms and conditions

Please read the Code of Conduct for BALP Sessions
Tick to confirm you have read and agree to these terms and conditions. By not agreeing you will not be allowed to participate in BALP sessions.

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